Alberto Aiolfi

Current status of minimally invasive endoscopic management for Zenker diverticulum

Surgical resection has been the mainstay of treatment of pharyngoesophageal (Zenker) diverticula over the past century. Developments in minimally invasive surgery and new endoscopic devices have led to a paradigm change. The concept of dividing the septum between the esophagus and the pouch rather than resecting the pouch itself has been revisited during the last three decades and new technologies have been investigated to make the transoral operation safe and effective. The internal pharyngoesophageal myotomy accomplished through the transoral stapling approach has been shown to effectively relieve outflow obstruction and restore physiological bolus transit in patients with medium size diverticula. Transoral techniques, either through a rigid device or by flexible endoscopy, are gaining popularity over the open surgical approach due the low morbidity, the fast recovery time and the fact that the procedure can be safely repeated. We provide an analysis of the the current status of minimally invasive endoscopic management of Zenker diverticulum.

Early outcome of thoracoscopic and hybrid esophagectomy: Propensity-matched comparative analysis

BACKGROUND Transthoracic esophagectomy remains the current therapeutic standard for localized esophageal carcinoma. Minimally invasive surgery has proven at least equivalent to open surgery regarding the early outcomes, but only 1 randomized study has compared the thoracoscopic with the thoracotomy approach. The primary objective of this study was to assess the early outcome of the thoracoscopic prone esophagectomy (TPE) and the hybrid Ivor Lewis (HIL) esophagectomy in 2 concurrent patient cohorts. METHODS We compared the 1-year outcome of 3-stage TPE and 2-stage HIL done over the same time period in a single center. The propensity score matching method was used to reduce selection bias by creating 2 groups of patients similarly likely to receive a treatment on the basis of measured baseline characteristics. After generating propensity scores using the covariates of age, sex, body mass index, forced expiration volume at 1 second, Charlson comorbidity index, American Society of Anesthesiologists score, histologic tumor type, tumor site, pTNM stage, and neoadjuvant therapy, 93 TPE patients were matched with 197 HIL patients using a 1:1 ratio and the nearest-neighbor score matching. Main outcome measure was the incidence of postoperative complications. RESULTS Operative time was longer in TPE patients (P < .01). All postoperative outcomes, including morbidity, mortality, nodal harvest, R0 resection rate, and 1-year survival rates were similar in the 2 matched groups. CONCLUSION Both operative approaches are safe and effective; using 1 or the other depends on the tumor site, surgeon experience and preference, and patient expectations.

Management of Boerhaave's syndrome with an over-the-scope clip.

Boerhaaves syndrome is a spontaneous barotraumatic disruption of the distal oesophagus secondary to an abrupt increase in intraoesophageal pressure during vomiting. Management ranges from a conservative approach to an oesophagectomy. The over-the-scope-clip (OTSC, Ovesco Endoscopy GmbH, Tuebingen, Germany) system is a newly designed clipping method for tissue mechanical compression in the gastrointestinal tract. We report the case of a patient referred with a delayed diagnosis of Boerhaaves syndrome and successfully treated by OTSC application followed by lung decortication.

Giant leiomyoma of the gastroesophageal junction: technique and results of endoscopic full-thickness resection.

Four consecutive patients with a giant leiomyoma originating from the posterior aspect of the gastroesophageal junction were treated with full-thickness endoscopic retroflex dissection. A complete removal of the lesion was obtained in all cases. No complications were observed except for some degree of air filtration causing symptomatic pneumoperitoneum in one patient. Retroflex endoscopic full-thickness resection of giant leiomyoma at the gastroesophageal junction is feasible and safe.

Splenic rupture following colonoscopy: Case report and literature review.

Highlights • Colonoscopy is a safe and routinely performed diagnostic and therapeutic procedure for different large bowel diseases.• Splenic injury is a rare complication of colonoscopy with few cases described; the first one was in 1974.• No specific causes have been established but probably the mechanism of injury may be related to direct trauma or excessive traction on the splenocolic ligament.• Clinical presentation occurs generally within the first 24 h after colonoscopy but in some cases a late presentation is described (more than 48 h) with subtle symptoms and arduous diagnosis.• Treatment should be addressed to clinics, splenic injury grading and hemodynamic status of patients

Stent-in-stent, a safe and effective technique to remove fully embedded esophageal metal stents: case series and literature review

Background: Endoscopic stenting is a widely used method for managing esophageal anastomotic leaks and perforations. Self-expanding metal stents (SEMSs) have proved effective in sealing these defects, with a lower rate of displacement than that of self-expanding plastic stents (SEPSs) as a result of tissue proliferation and granulation tissue ingrowth at the uncovered portion of the stent, which anchor the prosthesis to the esophageal wall. Removal of a fully embedded stent is challenging because of the risk of bleeding and tears. Materials and methods: Temporary placement of a new stent within the first stent (stent-in-stent technique) may facilitate the mobilization and safe removal of both stents by inducing pressure ischemia of the granulation tissue. We report our own experience with the stent-in-stent technique in five consecutive patients in whom a partially covered Ultraflex stent had previously been implanted and compare our results with those in the current literature. Results: The first SEMSs remained in place for a median of 40 days (range 18 – 68) without displacement. Placement of the new stent was technically successful in all patients. All stents were left in place for a median of 9 days. The overall stent-in-stent success rate was 100 % for the removal of embedded stents. No serious adverse events related to the procedure occurred. Conclusion: The procedure was safe, well tolerated, and effective. The use of a partially covered Ultraflex stent of the same size as the old stent for a limited time (≤ 6 days) was consistently successful.

Splenic artery embolization versus splenectomy: Analysis for early in-hospital infectious complications and outcomes

BACKGROUND Splenic artery embolization (SAE) has gained increasing acceptance as an important adjunct in the treatment of splenic injuries. Residual immunologic function of the spleen after embolization and its consequences on early infectious complications still remain intensely debated. The purpose of this study was to compare SAE and splenectomy (SP) in terms of early in-hospital infectious complications and outcomes. METHODS Two-year retrospective Trauma Quality Improvement Program database prognostic study. Patients with grade IV to V splenic injury requiring SAE or SP were included in the final analysis. Examined variables were demographics, mechanism of injury, Abbreviated Injury Scale (AIS), Injury Severity Score, Organ Injury Scale, admission vital signs, blood transfusion in the first 24 hours, early infectious complications, and outcomes. Multivariate analysis adjusted for patient and injury-related variables was used to identify independent predictors for infectious complication and mortality. RESULTS During the study period, 4,063 patients with a grade IV to V splenic injury managed with SAE or SP were included in the study. SAE was performed in 461 (11.3%) patients. The early infectious complication rate was 23.1% in the SP group and 11.7% in the SAE group (p < 0.001). Stepwise logistic regression analysis identified age 65 years or older, Glasgow Coma Scale (GCS) score less than 9, Head AIS score of 3 or greater, SP, and blood transfusion in the first 24 hours as independent predictors for early infectious complications. The unadjusted overall mortality was 12.7% in the SP group and 5.4% in the SAE group (p < 0.001). Age 65 years or older, GCS score less than 9, hypotension, head AIS score of 3 or greater, and blood transfusion in the first 24 hours were independent risk factor for mortality. SP was not an independent risk factor in terms of mortality. Subgroup analysis in patients with isolated splenic injury showed age 65 years or older, GCS score less than 9, and blood transfusion in the first 24 hours as independent factors associated with early infection. CONCLUSION Our study supports the effectiveness of SAE in hemodynamically stable patients with a grade IV to V splenic injury. SP is associated with an increased risk of early infectious complications but is not an independent risk for mortality. LEVEL OF EVIDENCE Therapeutic study, level IV.

Esophagectomy for End-Stage Achalasia: Systematic Review and Meta-analysis

BackgroundIndications for surgery and clinical outcomes of esophagectomy in the management of end-stage achalasia are not clearly defined. The aim of this systematic review and meta-analysis was to provide evidence-based information to help in the decision-making and in the choice of surgical technique.MethodsAn extensive literature search was conducted to identify all reports on esophagectomy for end-stage achalasia patients over the past three decades. MEDLINE, Embase and Cochrane databases were thoroughly consulted matching the terms “achalasia,” “end-stage achalasia,” “esophagectomy” and “esophageal resection” with “AND” and “OR.” Short- and long-term outcome data were extracted. Pooled prevalence of pneumonia, anastomotic leakage and mortality were calculated using Freeman–Tukey double arcsine transformation and DerSimonian–Laird estimator in random effect meta-analysis. Heterogeneity among studies was evaluated using I2-index and Cochrane Q test. Meta-regression was used to address the effect of potential confounders.ResultsEight papers published between 1989 and 2014 matched the inclusion criteria. In total, 1307 patients were included. Esophagectomy was performed through a transthoracic (78.7%) or a transhiatal (21.3%) approach. The stomach was used as an esophageal substitute in 95% of patients. Pooled prevalence of pneumonia, anastomotic leakage and mortality were 10% (95% CI 4–18%), 7% (95% CI 4–10%) and 2% (95% CI 1–3%), respectively.ConclusionsEsophagectomy for end-stage achalasia is safe and effective. Based on the results of this study, esophagectomy should be performed without hesitation in patients who are fit for major surgery and present with disabling symptoms, poor quality of life and dolichomegaesophagus recalcitrant to multiple endoscopic dilatations and/or surgical myotomies.

Hybrid and total minimally invasive esophagectomy: how I do it

Esophagectomy is a major surgical procedure associated with a significant risk of morbidity and mortality. Minimally invasive esophagectomy is becoming the preferred approach because of the potential to limit surgical trauma, reduce respiratory complications, and promote earlier functional recovery. Various hybrid and total minimally invasive surgical techniques have been introduced in clinical practice over the past 20 years, and minimally invasive esophagectomy has been shown equivalent to open surgery concerning the short-term outcomes. Implementation of a minimally invasive esophagectomy program is technically demanding and requires a significant learning curve and the infrastructure of a dedicated multidisciplinary center where optimal staging, individualized therapy, and perioperative care can be provided to the patient. Both hybrid and total minimally invasive techniques of esophagectomy have proven safe and effective in expert centers. The choice of the surgical approach should be driven by preoperative staging, tumor site and histology, comorbidity, patients anatomy and physiological status, and surgeons experience.

Intracranial pressure monitoring in severe blunt head trauma: does the type of monitoring device matter?

OBJECTIVE Intracranial pressure (ICP) monitoring has become the standard of care in the management of severe head trauma. Intraventricular devices (IVDs) and intraparenchymal devices (IPDs) are the 2 most commonly used techniques for ICP monitoring. Despite the widespread use of these devices, very few studies have investigated the effect of device type on outcomes. The purpose of the present study was to compare outcomes between 2 types of ICP monitoring devices in patients with isolated severe blunt head trauma. METHODS This retrospective observational study was based on the American College of Surgeons Trauma Quality Improvement Program database, which was searched for all patients with isolated severe blunt head injury who had an ICP monitor placed in the 2-year period from 2013 to 2014. Extracted variables included demographics, comorbidities, mechanisms of injury, head injury specifics (epidural, subdural, subarachnoid, intracranial hemorrhage, and diffuse axonal injury), Abbreviated Injury Scale (AIS) score for each body area, Injury Severity Score (ISS), vital signs in the emergency department, and craniectomy. Outcomes included 30-day mortality, complications, number of ventilation days, intensive care unit and hospital lengths of stay, and functional independence. RESULTS During the study period, 105,721 patients had isolated severe traumatic brain injury (head AIS score ≥ 3). Overall, an ICP monitoring device was placed in 2562 patients (2.4%): 1358 (53%) had an IVD and 1204 (47%) had an IPD. The severity of the head AIS score did not affect the type of ICP monitoring selected. There was no difference in the median ISS; ISS > 15; head AIS Score 3, 4, or 5; or the need for craniectomy between the 2 device groups. Unadjusted 30-day mortality was significantly higher in the group with IVDs (29% vs 25.5%, p = 0.046); however, stepwise logistic regression analysis showed that the type of ICP monitoring was not an independent risk factor for death, complications, or functional outcome at discharge. CONCLUSIONS This study demonstrated that compliance with the Brain Trauma Foundation guidelines for ICP monitoring is poor. In isolated severe blunt head injuries, the type of ICP monitoring device does not have any effect on survival, systemic complications, or functional outcome.